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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Spine Publish Ahead of Print DOI: 10.1097/BRS.0b013e31825d32f5

Primary care referral of patients with low back pain to physical therapy:

impact on future healthcare utilization and costs

Julie M. Fritz, PT, PhD, ATC, Associate Professor, Department of Physical Therapy,

University of Utah and Clinical Outcomes Research Scientist, Intermountain Healthcare,

Salt Lake City, Utah

John D. Childs, PT, PhD, Associate Professor and Director of Research, US Army-Baylor

University Doctoral Program in Physical Therapy, Ft Sam Houston, San Antonio, Texas

Robert S. Wainner, PT, PhD, Associate Professor, Texas State University – San Marcos,

San Marcos, Texas

Timothy W. Flynn, PT, PhD, Distinguished Professor, Rocky Mountain University of

Health Professions

Dr. Fritz is the corresponding author and will receive all reprint requests at the address

below:

University of Utah

Department of Physical Therapy

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520 Wakara Way

Salt Lake City, UT 84108

Phone: (801) 581-6297

Fax: (801) 585-5629

e-mail: [email protected]

This project was supported financially by grants from the Orthopedic and Private Practice

Sections of the American Physical Therapy Association and the American Academy of

Orthopaedic and Manual Physical Therapists. Funds were also provided by a faculty grant

from Texas State University.

Acknowledgements

The authors wish to acknowledge Mercer Health and Benefits, LLC for their assistance

with data acquisition and analysis for this project. This project was supported financially

by grants from the Orthopedic and Private Practice Sections of the American Physical

Therapy Association and the American Academy of Orthopaedic and Manual Physical

Therapists. Funds were also provided by a faculty grant from Texas State University.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency

for this indication. Orthopedic and Private Practice Sections of the American Physical

Therapy Association and the American Academy of Orthopaedic and Manual Physical

Therapists and Texas State University grant funds were received in support of this work.

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No benefits in any form have been or will be received from a commercial party related

directly or indirectly to the subject of this manuscript.

STUDY DESIGN:

Retrospective cohort

OBJECTIVE:

To describe physical therapy utilization following primary care consultation for low back

pain (LBP) and evaluate associations between the timing and content of physical therapy

and subsequent healthcare utilization and costs.

SUMMARY OF BACKGROUND DATA:

Primary care management of LBP is highly variable and the implications for subsequent

costs are not well-understood. The value of referring patients from primary care to

physical therapy has been debated, and information on how the timing and content of

physical therapy impact subsequent costs and utilization is needed.

METHODS:

Data were extracted from a national database of employer-sponsored health plans.

32,070 patients with a new primary care LBP consultation were identified and

categorized based on the use of physical therapy within 90 days. Patients utilizing

physical therapy were further categorized based on timing (early (within 14 days) or

delayed) and content (guideline adherent or non-adherent). LBP-related healthcare costs

and utilization in the 18-months following primary care consultation were examined.

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RESULTS:

Physical therapy utilization was 7.0% with significant geographic variability. Early

physical therapy timing was associated with decreased risk of advanced imaging (OR =

0.34, 95% CI: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32),

surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and

opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) as compared with delayed physical

therapy. Total medical costs for LBP were $2736.23 lower (95% CI: 1810.67, 3661.78)

for patients receiving early physical therapy. Physical therapy content showed weaker

associations with subsequent care.

CONCLUSION:

Early physical therapy following a new primary care consultation was associated with

reduced risk of subsequent healthcare compared with delayed physical therapy. Further

research is needed to clarify exactly which patients with LBP should be referred to

physical therapy; however if referral is to be made, delaying the initiation of physical

therapy may increase risk for additional healthcare consumption and costs.

KEYWORDS: primary care, physical therapy, health services research

MINI ABSTRACT

This study evaluated utilization of physical therapy following a new primary low back

pain care consultation. Overall, 7% of patients received physical therapy within 90 days

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with significant geographic variation. Early physical therapy was associated with

reduced risks of healthcare utilization and reduced costs over an 18-month follow-up

compared to delayed utilization.

KEY POINTS

· This study examined the utilization of physical therapy within 90 days of a new

primary care consultation for low back pain and associations with subsequent

healthcare utilization and costs using a national database of employee-based

healthcare insurance plans.

· Utilization of physical therapy occurred in 7.0% of patients with significant

geographic variation.

· Compared with the entire sample of patients, healthcare costs were higher for patients

utilizing physical therapy

· Among patients utilizing physical therapy, early referral (within 14 days of the

primary care consultation) was associated with reduced risk of subsequent healthcare

utilization including advanced imaging, additional physician visits, major surgery,

lumbar spine injections, and opioid medications, and lower overall healthcare costs.

Introduction

Considering the high prevalence of low back pain (LBP),1 it is not surprising that the

condition accounts for 2.5% - 3% of all physician visits in the United States,2-4 and is

responsible for substantial healthcare spending. Annual direct healthcare costs were

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estimated at over 85 billion dollars nationally in 2005, a 65% increase from 1997.5

Despite increasing expenditures, the prevalence of chronic, disabling LBP is

increasing.5,6

Most patients with LBP initially access healthcare through primary care.7,8 Decisions in

this setting likely have substantial impact on outcomes and costs.9 Defining optimal

primary care management has proven elusive, and wide variations in practice have been

observed for decisions such as medications, imaging, and referrals including physical

therapy10-12 Practice guidelines generally recommend delaying referral for physical

therapy for several weeks following initial consultation.13,14 Rationale for this

recommendation is that most patients recover rapidly, and intervening quickly would

waste resources and could impede recovery for some by excessively “medicalizing” the

condition.15,16 Delaying physical therapy is questioned by studies suggesting reduced

costs or improved outcomes with early use.8,17 In practice, many patients are managed

with early physical therapy instead of the recommended initial waiting period.18

The value of referring newly consulting patients with LBP from primary care to physical

therapy likely depends on both the timing of referral as well as the content of care

delivered. There appears to be wide variation in physical therapy care provided to

patients with LBP.19,20 Guidelines recommend an active approach with the focus on

strategies to help patients maintain and improve activity levels.21 Adherence to this

recommendation has been associated with improved outcomes and lower subsequent

healthcare utilization and costs.22,23

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Further research is needed to examine implications of the decision to refer new LBP

consulters from primary care to physical therapy, particularly the impact of timing and

content of care. Purposes of this study were to describe utilization of physical therapy by

primary care physicians for patients with a new consultation for LBP and evaluate the

impact of the timing and content of physical therapy care on subsequent healthcare

utilization and costs.

MATERIALS and METHODS

Description of the Data Source

Data source for this study was Mercer HealthOnline®, a multi-vendor data warehouse

maintained by Mercer Health and Benefits, LLC (San Francisco, California). The

database links claims and demographic data using anonymous coded numbers to protect

patient privacy. The database stores up to three years of history and is updated monthly

via an electronic feed from each data supplier. The database currently reflects the

combined experience of more than 2 million members of employer-sponsored health

plans. Project data had no identifying information. The project was approved by the

xxxxxx Institutional Review Board.

Identification of the Study Sample

We identified patients with a new consultation with a primary care physician with a

principle LBP diagnosis from November 1, 2007 through January 31, 2009. Date of the

new consultation was defined as the primary care index date. A LBP diagnosis was

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identified when a LBP-related ICD-9 code was the primary diagnosis (see Appendix

Table 1, Supplemental Digital Content 1, http://links.lww.com/BRS/A672). Patients had

to be continuously eligible within the database for 6 months before and 18 months after

the index date. Only the first eligible index date for an individual patient was included.

Further eligibility requirements were; age between 18-60 years on the index date, no

claims with a LBP-related ICD-9 code for 6 months preceding the index date, a co-

morbid diagnosis at the index date that could be a non-musculoskeletal source of LBP

(e.g., kidney stones, urinary tract infection, etc.) (see Appendix Table 2, Supplemental

Digital Content 1, http://links.lww.com/BRS/A672), or a prior history of spinal surgery

based on the presence of related CPT-4 codes at any time prior to the index date (see

Appendix Table 3, Supplemental Digital Content 1, http://links.lww.com/BRS/A672).

Covariate Variables

We recorded the following at the index date; patient’s age and gender, co-payment for

the index visit, employment status (active, retiree, long-term disability (LTD), or other),

and geographic region (Northeast (CT, DC, MA, ME, NH, NJ, NY, PA, RI, VT), South

(AL, AR, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV), Midwest

(IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, WI), or West (AK, AZ, CA, CO, HI,

ID, MT, NM, NV, OR, UT, WA, WY). The type of insurance plan was categorized

within the database as a health maintenance organization (HMO) which is generally

characterized by requirements for in-network services and referral for care through a

primary care provider, a preferred provider organization (PPO) which typically provides

more flexibility in choice of providers, point-of-service (POS) which are typically seen as

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hybrids of HMO and POS plans with higher co-payments for out-of-network services, a

high deductible health plan (HDHP) with low premium costs but high deductibles, or

other.

We recorded co-morbid healthcare conditions within a 6-month period preceding the

index date. We recorded the total number of unique ICD-9 diagnoses and the number of

prescription medications based on unique Generic Product Identifiers (GPI8). We

recorded if a hospitalization occurred for any reason, if opioids were prescribed, and total

costs for all services during the period including inpatient, outpatient and prescriptions.

We identified co-morbid conditions that may influence LBP prognosis including mental

health (depression, anxiety, or other psychotic disorders), neck/thoracic pain, or

fibromyalgia by identifying relevant ICD-9 codes.(see Appendix Table 4, Supplemental

Digital Content 1, http://links.lww.com/BRS/A672)

Physical Therapy Utilization

We considered a 90-day period after the primary care index date to identify physical

therapy utilization. If a physical therapy visit occurred with a LBP-related ICD-9 during

this period the patient was defined as utilizing physical therapy. Patients with both

physical therapy and chiropractic utilization during this period were not included in

further analyses. Patients utilizing physical therapy within 90 days were categorized as

receiving early physical therapy if the initial visit occurred < 14 days from the primary

care index date. We selected a 14-day period to represent a time frame that would clearly

link the initiation of physical therapy to the primary care index date with low likelihood

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of intervening treatment. If the visit occurred between 15-90 days from the index date the

patient was categorized as receiving delayed physical therapy.

Physical therapy content was examined using Current Procedural Terminology (CPT)

codes associated with all visits received during the physical therapy episode of care. An

episode of care was defined as the number of days between initial and final visits. If no

visits occurred for more than 30 consecutive days the episode of care was considered

complete. If only one physical therapy visit was received the patient was not included in

the analysis of content of care because these patients did not have an adequate number of

visits over which to judge the content of the episode of care. We examined CPT codes to

determine adherence to the guideline recommendation for active physical therapy

treatment21 using procedures described elsewhere.23 Briefly, each CPT code at each visit

was categorized as active, passive, or allowed. Active codes were those consistent with

guideline recommendations (e.g, therapeutic exercise, self-training management, etc.).

Passive codes were those indicating procedures inconsistent with guideline

recommendations (e.g., hot/cold packs, ultrasound, etc.). Allowed codes included

evaluation and equipment codes. Numbers of active and passive codes were totaled for

visits during the first 14 days of the episode of care (phase I); and beyond 14 days (phase

II). For each phase, the active percentage was calculated as: (number of active codes /

(number of active codes + number of passive codes) * 100%). Adherence required the

active percentage within each phase to be > 75%, and each visit to include > 1 active

code, otherwise the episode of care was considered non-adherent.

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Outcome Variables

We examined an 18-month period beginning with the index date to determine healthcare

utilization and costs. We recorded utilization of the following when related to a LBP

ICD-9 code: advanced imaging (MRI or CT), additional physician visits, lumbar spine

injection, major lumbar surgery (discectomy, laminectomy, rhizotomy or fusion), and

opioid medication use. We recorded costs during this period for expenditures in the

following categories when related to a LBP ICD-9 code; diagnostic/imaging procedures,

physician office visits, surgical/injection procedures, inpatient non-surgical costs,

emergency room visits, and prescription medications. Any other healthcare costs

(including physical therapy) related to a LBP ICD-9 code was recorded. Total LBP-

related healthcare costs were calculated as the sum of all categories. Non-LBP healthcare

costs during the 18-month period were recorded.

Data Analysis

Descriptive statistics were calculated. Multivariate logistic regression was used to

identify factors associated with physical therapy utilization considering all covariates as

potential predictors. We further examined descriptive variables, subsequent healthcare

utilization and costs (LBP-related and non-LBP-related) for patients utilizing physical

therapy based on the timing (early or delayed) and content (adherent or non-adherent) of

care. Utilization outcomes were compared using odds ratios with 95% confidence

intervals. We examined the relationship between total LBP-related costs and physical

therapy utilization using multivariate linear regression controlling for all covariates.

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RESULTS

76,967 continuously-eligible patients were identified with a primary care visit for LBP, of

whom 32,070 (41.7%) were included (figure 1). Physical therapy was utilized within 90

days for 2,234 (7.0%). The mean number of physical therapy visits was 6.4 (sd = 5.1).

Both physical therapy and chiropractic was utilized by 157 patients (0.49%). Baseline

characteristics are provided in table 1.

Predictors of Physical Therapy Utilization

Predictors of physical therapy utilization were evaluated using 31,482 patients (98.2%)

with complete data. Significant predictors were higher index visit co-payment (adjusted

odds ratio (aOR) = 1.02, p=0.022), not receiving long-term disability (aOR = 0.21,

p=0.04), having more diagnosis codes at the index visit (aOR = 1.04, p<0.001), and not

having co-morbid neck/ thoracic pain (aOR = 0.76, p<0.001). Geographic region

predicted utilization. With Midwest as the reference, utilization was predicted by living

in the Northeast (aOR = 1.59, p<0.001) or West (aOR = 1.61, p<0.001), and not living in

the South (aOR = 0.82, p=0.004).

Timing of Physical Therapy Utilization

Median time to physical therapy was 14 days (interquartile range: 6, 33). 1,102 (53.1%)

patients were categorized as receiving early physical therapy, and 975 (46.9%) received

delayed physical therapy. Patients receiving early physical therapy were less likely to be

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taking opioids at index visit (p = 0.023). Differences were evident based on insurance

plan. Of patients utilizing physical therapy with a PPO plan (n=1,493), a higher

percentage received early physical therapy (n=803, 53.4%) compared to patients with an

HMO plan (n=159), of whom 71 (44.7%) received early physical therapy (p=0.028).

Differences based on geographical region were present. Patients utilizing physical

therapy in the Midwest had a higher percentage with early physical therapy (n=189,

58.7%) compared to the South (n=274, 49.3%) (p=0.007).

Content of Physical Therapy Initial Management

Of 2,234 patients receiving physical therapy, 317 (14.2%) received one visit. Of the

remaining 1,917 patients, 413 (21.5%) were categorized as adherent to the

recommendation for active treatment, and 1,504 (78.5%) were non-adherent. Patients

receiving adherent care were more likely to be male (p=0.004) and had fewer prescription

medications at the index visit (table 1). Rates of adherence differed geographically, with

higher percentage of patients utilizing physical therapy receiving adherent care in the

Midwest (27.4%) and South (26.0%) than in the Northeast (16.8%) or West (18.1%)

(p<0.05).

Subsequent Healthcare Utilization and Costs

Healthcare utilization is detailed in table 2. As compared with delayed physical therapy,

patients with early physical therapy had an decreased likelihood of advanced imaging

(OR = 0.34, 95% CI: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21,

0.32), major surgery (OR = 0.45, 95% CI: 0.32, 0.64), lumbar spine injections (OR =

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0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93)

(figure 2). Relative to patients receiving non-adherent care, those receiving adherent

physical therapy had a decreased likelihood of surgery (OR = 0.61, 95% CI: 0.38, 0.98)

and receiving injections (OR = 0.66, 95% CI: 0.48, 0.91) (figure 3). Subsequent

healthcare costs during the 18 month follow-up period are outlined in table 3. As

compared to patients with delayed physical therapy, total LBP-related costs for patients

receiving early physical therapy were an average $2736.23 lower (95% CI: 1810.67,

3661.78). For patients receiving adherent versus non-adherent physical therapy, total

LBP-related costs were an average $1374.30 lower (95% CI: 202.28, 2546.31).

DISCUSSION

This study evaluated a large sample of patients newly consulting a primary care physician

for LBP. Physical therapy utilization was predicted by patient-related variables.

Substantial geographic variation was observed. Despite guideline recommendations to

delay physical therapy, about half the patients receiving physical therapy did so within 2

weeks. Use of physical therapy was associated with higher LBP-related costs over an 18-

month period. Among patients utilizing physical therapy, we found strong associations

between the timing of physical therapy and subsequent healthcare utilization and LBP-

related costs. Patients with early physical therapy had decreased likelihood of advanced

imaging, additional physician visits, surgery, injections and opioid use. We identified

weaker associations based on the content of physical therapy care.

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Geographic variation in physical therapy utilization is consistent with reports of other

LBP interventions including imaging, opioids, surgery, and injections.24-28 Reasons

underlying geographic variation are likely numerous and cannot be confirmed from this

study. Other research has identified provider density as a factor related to utilization of

LBP services.26 Utilization of MRI has been related to physician ownership of the

equipment.29 We were unable to determine physical therapist density within regions, or

the ownership of physical therapy clinics. We found the highest rates of physical therapy

utilization in the Northeast and West, with rates more than double for the South. The

Northeast is reported to have the lowest rates of surgery and injections for LBP, with

highest utilization of these procedures in the Midwest and South respectively.24,26

Viewed collectively with our results, it does not appear that regional differences are

attributable to an overall more aggressive attitude towards management of LBP in certain

areas. Instead, it seems that preferred management patterns may differ regionally.

Further research should explore this hypothesis and implications of different management

patterns on outcomes and costs

Physical therapy utilization in this sample was low (7%), but consistent with other reports

from large national databases.4,8,30 We found a majority of patients who went to physical

therapy did so quickly (within 2 weeks) after the primary care visit. A similar pattern has

been reported in Medicare enrollees with a new consultation for LBP,8 with 8.9%

receiving physical therapy within 90 days, of whom 74.2% received care within 4 weeks.

It appears that despite recommendations against early referral, when physical therapy is

used for patients with LBP it often occurs quickly after initial consultation. This practice

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may be justified by emerging evidence. We found early physical therapy was associated

with reduced risk of subsequent surgery, injections, physician visits, opioid use, and

advanced imaging, with a corresponding reduction in overall LBP-related medical costs

relative to delayed physical therapy. These findings are consistent with those reported for

Medicare patients,8 suggesting similar risks accompanying delayed referral across the age

spectrum.

There are several possible explanations for associations between physical therapy timing

and outcomes. Early physical therapy attendees may be those with less fear or

catastrophizing ideations related to LBP, and these beliefs may be responsible for better

outcomes.31 Consultation with any provider, however, has been related to psychosocial

factors such as low mood or diminished self-perception of coping ability,32,33 suggesting

individuals seeking both primary care and physical therapy are likely those lacking

confidence in their ability to self-manage. Physical therapy may contribute to promoting

a greater sense of self-reliance in managing LBP and confidence in a positive outcome.

The importance of developing these attributes of self-efficacy is emerging.34 If physical

therapy assists in developing self-efficacy, it is reasonable to expect it would have greater

impact when implemented very early, before negative expectations have become

reinforced and entrenched. This hypothesis may also help explain stronger associations

between timing, versus content, of physical therapy care, as the specific activities within

physical therapy may not be as important as the positive attitudes it promotes.

Alternatively, this finding could reflect the insufficiency of the standard by which we

judged the content of care. Randomized trials report that matching specific interventions

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to patients with particular clinical characteristics can improve the outcomes of physical

therapy for patients with LBP.35,36 More detailed examination of the content of physical

therapy and its adherence to specific clinical decision-making evidence may reveal a

greater impact on outcomes.

Contrary to studies showing positive associations between early physical therapy and

subsequent healthcare utilization, early use of MRI or opioids have demonstrated the

opposite relationships, increasing risks for future utilization.37-39 Use of these strategies

early in the course of care may have the detrimental effects of decreasing patients’

optimism for recovery or sense of control over symptoms. Several studies have found

providing information on MRI results to patients with acute LBP diminishes patients’

sense of well-being.40,41 The value of early physical therapy may be partly attributable to

providing an alternative, or counter-balance, to management strategies that foster a sense

of dependency in the patient. Additional research evaluating the factors underlying these

observations is needed; however it is increasingly evident that initial management

decisions following a new LBP consultation can have profound implications for

outcomes and downstream costs.

Although this study found associations between physical therapy timing and outcomes,

use of physical therapy was associated with higher LBP-related costs and increased

utilization of surgery and advanced imaging in particular relative to the overall sample.

These findings may reflect differences in severity and other important prognostic

indicators such as sciatica and psychosocial factors42 that we were unable to include. It

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may be that among patients with LBP who are at increased risk of persistent symptoms,

early use of physical therapy could reduce overall costs, however this hypothesis could

not be tested in this study. The most cost-effective management strategy would be

expected to occur if, after medical red flags or emergency conditions are identified and

appropriately referred, patients likely to benefit from physical therapy could be accurately

identified by primary care providers and referred early, while those at low risk are

managed within primary care. Screening tools designed to facilitate identification of

patients likely to benefit from early physical therapy have been developed and show

some promise.43

This study should be considered in light of additional limitations. Coding errors may

have existed within our dataset. We did not include pharmaceutical costs, which

contribute a small, but growing percentage of LBP-related costs.5,44 We did not measure

indirect or out-of-pocket costs for treatments such as complementary care, which is

common for LBP.45 We were unable to measure patient-centered outcomes such as pain

or satisfaction with care. We only included patients referred from a physician to physical

therapy. Almost all states permit direct access to physical therapy without a physician

referral, and direct access has been associated with reduced costs as compared to physical

therapy episodes of care that begin with a physician referral.46

Conclusion

Utilization of physical therapy within 90 days for newly consulting patients with LBP was

generally low, and varied across geographic regions. The timing of physical therapy

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utilization was strongly related to subsequent healthcare utilization and costs, with early

use associated with reduced risks of advanced imaging, surgery, injections, opioid use, and

lower overall healthcare costs as compared with delayed use.

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ACCEPTED


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ACCEPTED


Figure 1. Reasons for exclusion of patients from the analysis.

Figure 2. Likelihood of receiving specific services during the 18 month follow-up period

based on timing of physical therapy.

ACCEPTED


Figure 3. Likelihood of receiving specific services during the 18 month follow-up period

based on content of physical therapy.

ACCEPTED


APPENDIX TABLE 1 – ICD-9 Codes used to Identify Low Back Pain Code Description Code Description

721.3 Lumbosacral spondylosis without myelopathy

724.5 Backache, unspecified

722.1 Lumbar disc displacement 756.11 Spondylolysis, lumbosacral region

722.52 Lumbar/ lumbosacral disc displacement

756.12 Spondylolesthesis

722.73 Lumbar disc disease with myelopathy

846.0 Sprain - lumbosacral

722.93 Other disc disorder – lumbar region

846.1 Sprain - sacroiliac

724.02 Spinal stenosis-lumbar 846.8 Sprain – other specified sites of sacroiliac region

724.2 Lumbago 846.9 Sprain – unspecified site of sacroiliac region

724.3 Sciatica 847.2 Sprain – lumbar region

724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified

847.3 Sprain – sacrum

APPENDIX TABLE 2 - ICD-9 codes used to Identify Non-Musculoskeletal Reasons for Low Back Pain

ICD-9 code Description 592.xx Calculus of kidney 574.2 Calculus of gallbladder without mention of cholecystitis 599.0 Urinary tract infection, site not specified V13.02 Urinary (tract) infection 140.xx – 239.xx

Neoplasms

V17.81, V82.81

Osteoporosis

344.6 Cauda equine syndrome 730.xx Osteomyelitis, periostitis, and other infections involving bone 731.3 Major osseous deficit

ACCEPTED


APPENDIX TABLE 3 - CPT-4 codes used to Identify Prior Surgery for Low Back Pain

Code Description

00630 Anesthesia for procedures in lumbar region; not otherwise specified. 00670 Anesthesia for extensive spine and spinal cord procedures. 20930 Allograft for spine surgery only; morselized. 20936 Autograft for spine surgery only; local, obtained from same incision.

22102 Partial excision of posterior vertebral component for intrinsic bony lesion, single segment; lumbar.

22103 Partial excision of posterior vertebral component for intrinsic bony lesion, single segment; each additional segment.

22224 Osteotomy of spine, including diskectomy, anterior approach, single segment; lumbar.

22226 Osteotomy of spine, including diskectomy, anterior approach, single segment; each additional segment.

22558 Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace; lumbar.

22585 Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace; each additional interspace.

22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar 22630 Arthrodesis, posterior interbody technique, single interspace; lumbar 22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments. 22840 Insert spine fixation device 22842 – 22844

Posterior segmental instrumentation; 3 – 6 vertebral segments thru 13 or more segments

22851 Apply spine prosthetic device

62287 Aspiration procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar.

63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equine, without facetectomy, foraminotomy or diskectomy, (eg, spinal stenosis), one or two vertebral segments; lumbar, except for spondylolisthesis.

63011, 63012 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equine, without facetectomy, foraminotomy or diskectomy, one or two vertebral segments; sacral or lumbar

63030 Laminotomy with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar.

63035 Laminotomy with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; each additional interspace, cervical or lumbar.

63042 Laminotomy with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, re-exploration; lumbar.

63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 28quine and/or nerve root(s)) , single vertebral segment; lumbar.

63048 Removal of spine lamina – add-on

ACCEPTED


63088 – 63091

Vertebral corpectomy, partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equine or nerve root(s), lower thoracic or lumbar; each additional segment.

63185, 63190 Laminectomy with rhizotomy 63200 Laminectomy, with release of tethered spinal cord, lumbar.

63267, 63272 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural or intradural; lumbar.

63290 Laminectomy for biopsy/excision of intraspinal neoplasm; combined extra-intradural lesion, any level.

63303 Vertebral corpectomy, partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach.

63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root(s)) , single vertebral segment; lumbar.

63048 Removal of spine lamina – add-on 64622 Destruction by neurolytic agent; paravertebral facet joint nerve, lumbar, single level. 64623 Destruction by neurolytic agent; paravertebral facet joint nerve, lumbar, each additional level.

APPENDIX TABLE 4 - ICD-9 codes used to Identify Co-Morbid Conditions

Code Description

CO-MORBID MENTAL HEALTH CONDITIONS 296.xx Affective psychoses 297.xx Delusional disorders 298.xx Other nonorganic psychoses 300.xx Neurotic disorders 301.xx Personality disorders 308.xx Acute reaction to stress 309.xx Adjustment reaction 311.xx Depressive disorders, not elsewhere classified

CO-MORBID NECK / THORACIC PAIN: 721.0 Cervical spondylosis without myelopathy 721.1 Cervical spondylosis with myelopathy 721.2 Thoracic spondylosis without myelopathy 721.41 Spondylogenic compression of thoracic spinal cord 722.0 Displacement of cervical intervertebral disc without myelopathy 722.4 Degeneration of cervical intervertebral disc 722.51 Intervertebral disc disorder, thoracic or thoracolumbar region 722.71 intervertebral disc disorder without myelopathy – cervical 722.72 Intervertebral disc disorder without myelopathy, thoracic region 722.81 Post-laminectomy syndrome - cervical 722.91 other unspecified disc disorder – cervical region

ACCEPTED


723.xx Other disorders of cervical region 724.1 Pain in thoracic spine 739.1 Non-allopathic lesions not otherwise specified – cervical region 805 Fracture of cervical spine without spinal cord injury 847.0 Sprains and strains of other, unspecified part of the back - neck 953.0 Injury to nerve root and spinal plexus - cervical 954.0 Injury to other nerves of trunk - cervical

CO-MORBID FIBROMYALGIA 729.1 Myalgia and myositis, unspecified

ACCEPTED


Timing of Physical Therapy (n=2,077)

Content of Physical Therapy (n=1,917)

All Patients (n=32,070)

Utilized Physical Therapy (n=2,234) Early

(n=1,102) Delayed (n=975)

Adherent (n=413)

Non-Adherent (n=1504)

Age (mean, sd) 43.1 (10.1) 43.6 (9.9) 43.1 (10.2) 44.0 (9.5) 42.5 (10.3) 44.1 (9.7) Gender (% female) 53.9% 54.2% 56.6% 53.0% 48.4% 56.4%

Index visit co-payment (mean, sd) $26.56 (28.22)

$27.84 (30.10)

$28.55 (31.55)

$27.33 (28.59)

$28.93 ($34.33)

$27.95 ($29.43)

Insurance Plan PPO HMO POS HDHP Other

70.5% 8.6% 7.2% 3.0%

10.6%

72.2% 7.6% 6.3% 3.4% 10.6%

72.9% 6.4% 6.4% 3.4% 10.9%

70.8% 9.0% 6.4% 3.6% 10.3%

71.2% 6.5% 6.5% 5.1% 10.7%

73.1% 7.5% 6.2% 3.3% 10.0%

Employment status Active Retiree LTD other

97.3% 1.8%

0.27% 0.60%

97.0% 2.1%

0.090% 0.90%

96.8% 2.3%

0.091% 0.82%

97.0% 1.8% 0.10% 1.0%

96.9% 1.7% 0.24% 1.2%

96.9% 2.2% 0.07% 0.80%

Geographic region Northeast West South Midwest

16.8% 26.7% 38.6% 18.0%

21.9% 35.4% 27.1% 15.6%

21.8% 35.5% 25.3% 17.4%

22.8% 33.7% 29.5% 13.9%

17.7% 30.0% 32.7% 20.0%

23.9% 36.6% 25.2% 14.4%

Number of diagnosis codes (mean, sd) 6.5 (5.3) 7.1 (5.1) 7.0 (4.9) 7.1 (5.2) 6.8 (5.3) 7.3 (5.1) Number of prescription medications (mean, sd) 5.5 (5.4) 5.6 (5.4) 5.5 (5.4) 5.7 (5.4) 4.8 (4.7) 5.9 (5.5) Co-morbid mental health condition 9.6% 9.7% 9.5% 9.5% 7.7% 9.4% Co-morbid fibromyalgia diagnosis 2.4% 2.4% 1.7% 3.0% 1.7% 2.6% Co-morbid neck/thoracic spine condition 12.5% 11.1% 9.4% 11.7% 9.0% 11.8% Narcotic use prior to index visit 31.4% 33.3% 30.5% 35.2% 30.8% 34.0% Hospitalization prior to index visit 3.7% 3.7% 3.0% 4.6% 3.6% 3.7%

Total medical costs prior to index visit (mean, sd) $3193.08 ($7672.62)

$3422.01 ($5403.82)

$3168.58 ($4581.94)

$3574.32 ($5772.12)

$2971.61 ($4795.07)

$3567.91 ($5635.93)

Number of physical therapy sessions (mean, sd) 6.4 (5.1) 6.9 (5.6) 5.8 (4.5) 5.3 (3.9) 7.9 (5.1)

Table 1. Characteristics of patients with new consultations in primary care with low back pain (PPO = preferred provider organization, HMO = health maintenance organization, POS = point of service, HDHP = High deductible health plan, LTD = long term disability)

ACCEPTED


Timing of Physical Therapy (n=2,077)

Content of Physical Therapy (n=1,917)

All Patients (n=32,070) Early

(n=1,102) Delayed (n=975)

Adherent (n=413)


Advanced Imaging (MRI or CT)

18.9% 29.4% 54.9% 38.7% 43.9%

Additional Physician Visits 44.1% 52.6% 81.0% 64.4% 68.8%

Lumbar Spine Surgery 2.5% 4.7% 9.9% 5.1% 8.1%

Lumbar Spinal Injections 7.1% 10.1% 21.2% 12.6% 17.8%

Opioid Medication Use 49.1% 49.1% 55.3% 49.6% 53.2%

Table 2. Utilization of specific services for low back pain in the 18 month period following the index primary care visit

ACCEPTED


Timing of Physical Therapy (n=2,077) Content of Physical Therapy (n=1,917) All Patients

(n=32,070) Early (n=1,102)

Delayed (n=975)

Adherent (n=413)


Imaging Procedures $291.12 (5.42) $473.32 (63.92) $807.20 (42.12) $513.84 (46.82) $701.14 (52.32)

Physician Visits $209.54 (1.48) $259.62 (9.76) $411.76 (11.89) $295.52 (14.33) $357.15 (9.86)

Surgical/ Injection Procedures

$740.44 (36.84) $1018.88 (170.65) $2760.62 (381.27) $1445.23 (486.37) $1965.72 (229.42)

Inpatient Non-Surgical Procedures

$79.28 (11.13) $65.00 (30.58) $231.79 (64.52) $162.31 (90.20) $142.99 (37.81)

Emergency Room Visits $19.83 (0.87) $26.21 (4.89) $25.22 (4.59) $24.87 (6.94) $28.61 (4.36)

Prescription Medication $104.23 (3.01) $80.41 (10.22) $116.83 (11.27) $76.43 (9.85) $98.85 (9.61)

Other LBP-related Costs $437.89 (8.11) $1225.04 (52.10) $1531.3 (67.01) $1090.64 (89.06) $1651.73 (53.07)

Total LBP costs $1882.33 (44.58) $3148.49 (228.90) $5884.71 (429.92) $3608.83 (533.49) $4946.18 (277.19)

Non-LBP healthcare costs $7892.53 (108.75) $7169.22 (472.39) $8430.44 (761.80) $7254.82 (1155.66) $7511.44 (402.09)

Table 3. Costs incurred over the 18 month period following the index primary care visit. Values represent mean (standard error).

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